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Application # Z ✓ y
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR
MORTGAGE CO. FINANCING COMMERCIAL CHANGE OF OWNERSHIP
FIRE DAMAGE ETC
NOTE, A DEED OR OFFER TO PUA~'AA E IS REOUI Fn AT TIME OF A-PP► CATION
Date: / - .2a - 0
Proposed Buyer.
Applicant/Mortgage Co:
Mailing Address:
City:
Telephone: ( )
Current Land Owner. aW C Phone: Al
~f 9- l
rroperty ddress: + oZ 33.2
PIN: ~'8 7- Y!- 'J b L Parcel: a d o 0- /
Name of Subdivision: = Lot #-L5' l (te,wticabie)
Daycare: # of employees--&4_ # of children Flours:
Directions: (please give concise, complete directions from Lillingto , NC the property)
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There Is a $10000 charge for this service. This approval is subject to revocation if the
intended use of the septic system changes or if false information is provided on this
application.
Your signature below certifies that all above information is correct.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE OALY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Si ature of Environmental Health Specialist Date
State: Zip:
Fax:( )
8/07
143108 S